Heart Failure Education and Discharge Program

1. Heart Failure Education and Discharge Program

2. Program Contents ____________________________________________________________________ • Program Goals • Prevalence of HF • Definition of HF • Etiology / Types of HF • HF Classification Systems • Physiological Response to HF • Diagnostic Findings • Treatment: Medications • Core Measures • Teaching Process • Review

3. Program Goals_______________________________________________________________________ • For Patients • An organized and informed inpatient education process • An increased knowledge of the diagnosis and treatment pathway for heart failure

4. Program Goals_______________________________________________________________________ • For Nurses • Increased understanding of heart failure • Familiarity with HF therapies • Recognition of patients needing HF teaching • Ability to provide Heart Failure Education as part of the hospital’s Core Measure

5. Program Goals_______________________________________________________________________ • For the Hospital • Meeting and exceeding national standards of HF care • Compliance with TJC core measures • Reduce re-admission rates for HF patients

6. The Size of the Problem_______________________________________________________________________ • Approximately 5 million patients in this country have HF • Over 550,000 patients are diagnosed with HF for the first time each year • In 2001, nearly 53,000 patients died of HF as a primary cause • Accounts for 12 to 15 million office visits and 6.5 million hospital days each year

7. The Size of the Problem_______________________________________________________________________ • The incidence of HF approaches 10 per 1000 population after age 65 • HF is the most common Medicare diagnosis- related group • More Medicare dollars are spent on the diagnosis and treatment of HF than on any other diagnosis ACC,AHA 2009

8. Definition of Heart Failure_______________________________________________________________________ • HF is complex and difficult to define. • It can result from any of several structural or functional cardiac disorders that impair ventricular filling or ejection.

9. Definition of Heart Failure _______________________________________________________________________ • Some or all of these structural or functional changes may be present in varying degrees, without a precise correspondence to HF. • The heart may be damaged, but not failing.

10. Definition of Heart Failure _____________________________________________________________________ • There is no single diagnostic test for HF; rather • HF is diagnosed by history and clinical findings: • dyspnea and fatigue, which may limit exercise tolerance, and • fluid retention, which may lead to pulmonary congestion and peripheral edema.

11. Definition of Heart Failure _______________________________________________________________________ Because not all patients have volume overload at the time of initial or subsequent evaluation, the term “heart failure” is preferred over the older term “congestive heart failure.”

12. Etiology of Heart Failure_______________________________________________________________________ • The primary causes of heart failure are: • Coronary artery disease • Hypertension • Dilated cardiomyopathy • Risk Factors include: Hypertension, smoking, obesity, diabetes, metabolic syndrome, alcohol abuse, COPD, increasing age

13. Types of Structural/Functional changes that lead to Heart Failure_______________________________________________________________________ • Left ventricular systolic dysfunction (LVSD) • Diastolic dysfunction • Right sided failure • Cor Pulmonale

14. Types of Heart FailureLeft ventricular systolic dysfunction (LVSD)_______________________________________________________________________ • Impairment of the ventricle’s ability to contract forcefully and fully enough to provide adequate cardiac output. • Usually with diminished Ejection Fraction (EF). • This is “classic” heart failure, and the more familiar definition.

15. Types of Heart FailureDiastolic dysfunction_______________________________________________________________________ • Inability of the ventricle to fill adequately related to a “stiff” or non-compliant ventricular wall. The EF may be near normal in this type of failure • Although many of the signs and symptoms may be the same, this type of failure is treated somewhat differently

17. Types of Heart FailureRight Sided Failure_______________________________________________________________________ • May occur as a result of left-sided failure. When the left ventricle fails, increased fluid pressure is transferred back through the lungs, causing congestion, and ultimately damaging the heart's right side. When the right side loses pumping power, blood backs up in the venous system, seen as swelling in the legs and ankles. • Can also occur through direct damage (AMI) to the right ventricle

18. Types of Heart FailureCor Pulmonale_______________________________________________________________________ Any condition that leads to prolonged high blood pressure in the arteries or veins of the lungs (pulmonary hypertension) strains the right side of the heart. When the right ventricle fails or is unable to properly pump against these abnormally high pressures, cor pulmonale is the result.

19. Cor Pulmonale is dilation and hypertrophy of the right ventricle due to pulmonary hypertension, typically caused by chronic lung disease or sleep apnea. Dilation Hypertrophy

20. HF Classification Systems_______________________________________________________________________ The New York Heart Association (NYHA) established a classification system for HF, based upon the caregiver’s observations and assessments of the patient’s functional capacity. These Stages I-IV (“mild”, “mild”, “moderate”, “severe”) have been used for many years to describe the degree of failure.

21. New York Heart AssociationClasses of HF_______________________________________________________________________ Class I No limitation of physical activity. Ordinary physical activity does not cause undue fatigue, palpitation or dyspnea. Class II Slight limitation of physical activity. Comfortable at rest, but ordinary physical activity results in fatigue, palpitation or dyspnea. Class III Marked limitation of physical activity. Comfortable at rest, but less than ordinary activity causes fatigue, palpitation and dyspnea. Class IV Unable to carry out any physical activity without discomfort. Symptoms of cardiac insufficiency at rest. If any physical activity is undertaken, discomfort is increased

22. HF Classification Systems_______________________________________________________________________ It has been recognized for many years that the NYHA functional classification reflects a subjective assessment by a healthcare provider and can change frequently over short periods of time. It has also been recognized that the treatments used may not differ significantly across the NYHA classes.

23. HF Classification Systems_______________________________________________________________________ In 2009, the ACC/AHA Joint Committee on HF Guidelines believed that a staging system was needed that would reliably and objectively identify patients during the course of their developing disease. This would be linked to treatments uniquely appropriate at each stage of illness, and would recognize: • Ventricular dysfunction is progressive • Progress is in one direction due to the permanence of cardiac remodeling

24. Stages of Heart Failure _______________________________________________________________________ ACC/AHA 2009 Guidelines for the Diagnosis and Management of Heart Failure in Adults

25. HF Classification Systems_______________________________________________________________________ In this classification, movement through the prodromal structural changes of the early disease process and into the functional changes of frank HF is signaled by objective changes. Each Stage is associated with increased therapeutic interventions. The 2009 Staging System is intended to complement rather than replace the NYHA Classes.

26. Heart Failure is Progressive_______________________________________________________________________ • Control of this disease is a long term project. It cannot be cured, but signs and symptoms can be controlled, and disease progression slowed. • Treatment will vary related to the severity, “stage”, or “class” of failure

27. HF and Homeostasis_______________________________________________________________________ Perhaps the most difficult thing about this disease is that the body’s homeostatic response to early cardiac dysfunction actually aggravates the pathologic process.

28. Physiologic Response to Low Cardiac Output_______________________________________________________________________ • Increase in circulating catacholamines increased heart rate and afterload • Increase in angiotensin II and aldosterone increase in sodium and water retention • Later, an increase in B-type Natriuretic peptide • this is the body’s attempt to control salt and fluid retention, and afterload, once it recognizes fluid overload in the atria and ventricles

29. Ineffective Compensation_______________________________________________________________________ • The normal physiologic response to low cardiac output OVER TIME, aggravates the problem and worsens the injury! • Without intervention, heart failure can become a picture of rapid decompensation

30. Common Heart Failure Symptoms and Signs_______________________________________________________________________ • Symptoms Dyspnea, fatigue, edema, orthopnea (dyspnea when head is not elevated), paroxysmal nocturnal dyspnea, cough, anorexia • Signs Increasing jugular venous distension, S3 gallop, rales, edema

31. Common Diagnostic Findings_________________________________________________________________ • Echocardiogram • Evaluation of cardiac structure and function • Evaluation of left ventricular ejection fraction (EF) • The percentage of blood which is ejected from the left ventricle with each contraction • (normal ejection fraction is greater than 60%) • EF is a CORE MEASURE

32. Common Diagnostic Findings_______________________________________________________________________ • Chest X-Ray • May show evidence of fluid overload or pleural effusions • This may correlate with the clinical assessment of rales during lung auscultation • May show an enlarged cardiac silhouette

33. CXR With Fluid Overload and Enlarged Cardiac Silhouette

34. Common Diagnostic Findings_______________________________________________________________________ • Heart Catheterization May or may not be done depending on presentation, symptoms, whether new onset of disease or not, and whether there is ischemic heart disease • Stress test - as above Not recommended as a part of routine evaluation in patients with known heart failure

35. Common Diagnostic Findings-Laboratory_______________________________________________________________________ • B-type Natriuretic Peptide-BNP BNP is a substance secreted from the ventricles in response to changes in pressure that occur when heart failure develops and worsens. The level of BNP in the blood increases when heart failure symptoms worsen, and decreases when the heart failure condition is stable. The BNP level in a person with heart failure - even if the HF condition is stable - is higher than in a person with normal heart function.

36. Common Diagnostic Findings- Laboratory______________________________________________________________________ • BNP Levels • BNP levels below 100 pg/mL indicate no HF • BNP levels above 300 pg/mL indicate mild HF • BNP levels above 600 pg/mL indicate moderate HF • BNP levels above 900 pg/mL indicate severe HF.

37. Common Diagnostic Findings- Laboratory________________________________________________________________________ • Frequently ordered tests can include: electrolytes, glucose, magnesium, calcium, lipid panels, liver function tests • Abnormal findings in these tests are not specificto heart failure, but could be a contributing factor, or a result of heart failure • Some abnormal labs could be a result of treatment, for instance low potassium with diuresis

38. ECG Findings_______________________________________________________________________ • May show evidence of myocardial infarction or ischemia • May show evidence of left ventricular hypertrophy • May have other abnormalities such as arrythmias, bundle branch blocks, pathologic Q waves

39. Pathologic Q waves in an ECG may indicate a myocardial infarct, either recent or old. • They are deep, greater than one “box” on the graph paper • Here they are in the anterior leads. They are very conspicuous in V2 and V3 but are also in V4, 5, 6 and AVL

40. Common Treatments for HF:Ace Inhibitors (ACEI)_______________________________________________________________________ • Recommended in asymptomatic and symptomatic patients with an ejection fraction of less than 40% • ACE INHIBITORS (angiotensin converting enzyme inhibitors, or ACEI’s): enalapril (Vasotec), captopril (Capoten), lisinopril (Zestril, Prinivil) • ACEI is a CORE MEASURE

41. ACEI-Mechanism of Action_______________________________________________________________________ Angiotensin I is normally converted to angiotensin II by angiotensin converting enzyme (ACE), so an ACE inhibitor blocks formation of Angiotensin II

42. Angiotensin II_______________________________________________________________________ • Many of these effects of angiotensin II are harmful to the HF patient in the long term • Sodium and fluid retention • Increased catecholamine release resulting in increased heart rate and blood pressure • Cardiac “remodeling” resulting in left ventricular wall thickening

43. Beneficial Effects of ACEI’s______________________________________________________________________ • Decrease peripheral vascular resistance and lower blood pressure • Decrease the release of aldosterone and catecholamines Reduced sodium (and water) retention Decreased heart rate and blood pressure • Reduce abnormal cardiac “remodeling” Reduce cardiac hypertrophy

44. Angiotensin II Receptor Blockers(ARB’S)_______________________________________________________________________ • losartan (Cozaar), valsartan (Diovan) • Used in patients who require an ACEI, but cannot take them because of side effects or other problems • Especially useful in those patients who develop an ACEI related cough

45. Common Treatments for HF:Beta Blockers_______________________________________________________________________ • Recommended in heart failure with an ejection fraction of less than 40% • Used in combination with ACEI/ARB’s • Block the effects of sympathetic neurotransmitters (catecholamines) by competing at binding sites • Beta blockers are a CORE MEASURE

46. Beta Blocker Effects_______________________________________________________________________ • Anti-anginal agent: • decreases myocardial oxygen demand decreases both rate and contractility. • Cardioprotective: • inhibits circulating catecholamine stimulation • Class II antidysrhythmic: • useful in the control of tachydysrhythmias

47. Beta BlockersDecrease Cardiac Workload

48. Other Common HF Medications_______________________________________________________________________ • Diuretics • Loop Diuretics (like furosemide) • Thiazide Diuretics (like hydrochlorothiazide) • Potassium Sparing Diuretics • Amiloride • Spiranolactone-an aldosterone antagonist which reduces sodium and fluid retention • Nitrates • Isosorbide, Nitroglycerin

49. Other Common HF Medications_______________________________________________________________________ • Digoxin • Anticoagulants and Antiplatelet Drugs • Aspirin • Warfarin • Clopidogrel (after coronary interventions/stents) • Antidysrhythmics • Amiodarone (Cordarone), dofetilide (Tikosyn), flecainide (Tambacor), others.

50. The “Vicious Cycle”_______________________________________________________________________ The widespread incidence of HF is due to a difficult combination of factors: • Risk factors are common and not well controlled. • Progression from risk factor to HF is not curable, but it is generally controllable. • Numerous therapeutic choices arise within the natural history of the disease. • HF will worsen without careful attention to maintenance and therapy by patient and caregivers.